How To Stop Drinking During Pregnancy

Transcription

1 Social Policy and the Prevention of Alcohol use in Pregnancy Claire D. Coles, Ph.D. Department of Psychiatry and Behavioral Sciences Emory University School of Medicine Atlanta, Georgia, USA 1

2 Prevalence of drinking Many childbearing aged women drink alcohol. There are different levels of use in different subgroups. In the US, employed educated Caucasian women drink most heavily; poor African-American women in the Southeastern the least. 4% drink heavily (3 drinks/day) 35% of those who abuse alcohol have children with FAS; others may have pfas. 2

3 Reducing drinking in pregnancy Most women reduce drinking during pregnancy (80%) 61% abstain during pregnancy Most for physiological reasons Many for health reasons due to medical advice and public health messages 3

4 Assumptions Social Policy based on several assumptions: Alcohol use during pregnancy is undesirable Actions, direct or indirect, may be taken that will produce abstinence during pregnancy Government has the information required to decide on appropriate actions as well as the authority to implement these actions 4

5 Model for Prevention Activities Universal Prevention promoting the health and well-being of all individuals in the community, thru media and social policy Selected Prevention Focusing on high risk group, e.g., young women who drink alcohol Indicated Prevention Targeting groups demonstrating detectable signs, e.g., alcohol abuse in pregnancy IOM,

6 Universal Prevention Strategies Point of Sale Signage- Warning Signs where alcohol is sold. (Law requires in 17 US States.) Labeling laws- Advertisements (public service messages) Government Advisory- The US Surgeon General recommends that.., 6

7 Selected Prevention Strategies Training physicians to identify alcohol abuse Providing information about birth control to women who drink Designing information campaigns for specific communities 7

8 Indicated Prevention Strategies Identifying pregnant women who are using alcohol/drugs and providing treatment during pregnancy (e.g., Georgia) Mandatory reporting of alcohol/drug abusing women to protective services or legal authorities, (e.g., South Carolina) 8

9 Universal: Labeling of Containers US Public Law (1988) required as of 1989 that all containers of alcoholic beverages be labeled with clear nonconfusing language describing alcohol-related hazards. 9

10 Which reads, GOVERNMENT WARNING: (1) According the Surgeon General, women should not drink alcoholic beverages during pregnancy because of the risk of birth defects. (2) Consumption of alcoholic beverages impairs your ability to drive a car or operate machinery, and may cause health problems. 10

11 Are Warning Labels Effective? Do warning labels reduce drinking? What is the baseline level of drinking among high risk groups? Are container labels effective with high risk groups? What is the role of labels versus other prevention methods? 11

12 Research on Warning Labels Hankin, JR, Firestone, IJ, Sloan, JJ, Ager, JW., Goodman, AC, Sokol, RJ & Martier, SS. (1993) The impact of alcohol warning labels on drinking during pregnancy, J Publ Pol Market, 12, Kaskutas, L, Greenfield, TK, Lee, ME, & Cote, J (1998) Reach and effect of health messages on drinking during pregnancy. J Health Ed, 29,

13 Research on Warning Labels: Findings Mixed results Heavier Drinkers more familiar Self-report indicated compliance among nonrisk drinkers but not high risk in pregnancy First time mothers but not multiparious reduce drinking in pregnancy Not effective with most at risk women. Does not affect drinking in pregnancy. 13

14 Research on Adolescents MacKinnon, Nohre, L, Pentz, MA, & Stacy, AW (2000) The alcohol warning and adolescents: 5-year effects. Am J Pub H, 90, There is no beneficial change attributable to warning in beliefs, alcohol consumption, or driving after drinking. 14

15 Kaskutas, et al, 1998 Reviewed research on Universal prevention activities. Found that changes in drinking during pregnancy were not associated with exposure to any of the assessed messages (labels, posters, advertisements, and conversations). 15

16 Legal Intervention with Pregnant Women Mandated access to treatment Mandated treatment Criminal prosecution (240 women in 35 states prosecuted for prenatal conduct, usually drug use). In Wisconsin, criminal homicide when infant born with BAC of

17 Examples 1998, Wisconsin legislature gave judges authority to mandate inpatient treatment. Initially, health professionals were required to report pregnant women to authorities but this was amended. 17

18 Questions about Legal Interventions Is there anyway to measure the effect of these methods on alcohol use by women? On pregnancy outcomes? Are these methods effective in reducing negative outcomes of alcohol-affected pregnancies? 18

19 Legal Actions and pregnant women: References Berkowitz, G., Brindis, C., Clayson, Z., & Peterson, S. (1996) Options for recovery: Promoting success among women mandated to treatment. J Psychoactive Drugs 28, Chavkin, W., & Breitbart, V. (1997) Substance abuse and maternity: the United States as a case study. Addiction, 92,

20 Moral and Ethical Concerns Rights of pregnant Women vs. well being of Fetus Most legal approaches based on view that the fetus is endangered by maternal behavior and that action is required. Lack of treatment options for Pregnant women. Treatment often not available due to insurance, concerns about liability, etc. 20

21 Access to Treatment Treatment required to reduce drinking by high risk drinkers. Access to treatment related to funding for services, as well as other factors. Dual diagnosis and liability Medicaid eligibility (in US) Reducing other barriers to treatment 21

22 Medicaid and Welfare Reform 1996-Contract with America Act (PL ) -prohibits payment of public benefits to substance abusers and to promote treatment Prohibited disability benefits (SSI and SSDI) for addicts Eliminated Medicaid and Medicare eligibility for those whose SA is primary cause of disability. 22

23 Medicaid and Welfare Reform 1996-Personal Responsibility and Work Opportunity Reconciliation Act (PL ) -3 US Federal programs (AFDC;JOBS) replaced with a block grant called Temporary Assistance to Need Families (TANF) 23

24 Effects of Changes in Policy States and local governments more autonomy and flexibility 17 of 50 states sought exemption from restrictions on treatment of addicts TANF programs monitor drug use and mandate treatment. Time limits in place. Reduced access to substance abuse services in many areas 24

25 Access to Treatment: References Chavkin, W., Wise, PH, & Elman, D. (1998) Policies toward pregnancy and addiction: Sticks without carrots. Ann NY Acad Sci, 846, CSAT (1998) Substance abuse treatment and welfare reform. The Communiqué, Fall, Schmidt, LA., & McCarty, D. (2000) Welfare reform and the changing landscape of substance abuse services for low-income women. ACER, 24,

26 Complications Many social policies directed at reducing drinking during pregnancy have been implemented without foreseeing complications. Labeling effective with low-risk drinkers. Criminalization reduces prenatal care. Access to treatment reduced when Medicaid/disability coverage withheld from addicts and local control led to cutting funds 26

27 Conclusions Social policy must support a consistent message to be effective. Prevention activities must be multilevel to provide a social context for abstinence and to support abstinence among individual women. Outcomes of social policy interventions should be evaluated to avoid unintentional side effects. 27